The Medical Tune Up Dr. Debra Pugh MD, FRCPC Internal Medicine

The Medical Tune UpThe Medical Tune UpDr. Debra PughDr. Debra Pugh

MD, FRCPCMD, FRCPC

Internal MedicineInternal Medicine

ObjectivesObjectives

Review basic approach to managing Review basic approach to managing common medical issues in surgical common medical issues in surgical patientspatients

Managing DM peri-opManaging DM peri-op The Confused PatientThe Confused Patient Approach to ARFApproach to ARF Acute DyspneaAcute Dyspnea Managing Electrolyte abnormalitiesManaging Electrolyte abnormalities

Case 1Case 1

You are admitting a 70 year old man for You are admitting a 70 year old man for cholecystectomy after a recent episode of cholecystectomy after a recent episode of gallstone pancreatitisgallstone pancreatitis

Past Med Hx: DM II, CAD, HTN, COPDPast Med Hx: DM II, CAD, HTN, COPD Rx: ASA, ACE-I, beta-blocker, statin, Rx: ASA, ACE-I, beta-blocker, statin,

Metformin, insulin, inhaled bronchodilatorsMetformin, insulin, inhaled bronchodilators

Case 1Case 1

The nurse asks you what you want to do The nurse asks you what you want to do about the patient’s oral hypoglycemics and about the patient’s oral hypoglycemics and insulin on admissioninsulin on admission

DM in the Surgical PatientDM in the Surgical Patient

Peri-operative mortality is increased in Peri-operative mortality is increased in patients with DMpatients with DM

Most deaths from heart disease and Most deaths from heart disease and infectioninfection

Poor wound healing and increased Poor wound healing and increased frequency of wound infectionsfrequency of wound infections


Ideally BS 4-6Ideally BS 4-6 Peri-operatively the goal is to avoid Peri-operatively the goal is to avoid

excessive highs or lowsexcessive highs or lows Reasonable goal is BS < 11-14 to avoid Reasonable goal is BS < 11-14 to avoid

problems with wound healing and infectionproblems with wound healing and infection Intensive glucose control in ICU settingIntensive glucose control in ICU setting


Stresses of surgeryStresses of surgery ↑ ↑ catecholamines and cortisolcatecholamines and cortisol ↑↑gluconeogenesisgluconeogenesis ↑ ↑ glucagon release and ↓ insulin releaseglucagon release and ↓ insulin release ↑ ↑ muscle glucose usemuscle glucose use Drugs can ↑ insulin resistanceDrugs can ↑ insulin resistance

Can all lead to hyperglycemiaCan all lead to hyperglycemia

The Basics: DMThe Basics: DM

Type II (on oral agents only)Type II (on oral agents only) Hold meds the morning of ORHold meds the morning of OR If long-acting (glitazones) stop for 48-72 If long-acting (glitazones) stop for 48-72

hrshrs IV glucoseIV glucose Monitor BS q 6 hMonitor BS q 6 h Consider insulin infusionConsider insulin infusion

The Basics: DM PreopThe Basics: DM Preop

Type I or Type II on Insulin (If minor procedure)Type I or Type II on Insulin (If minor procedure) 1/3 to ½ of usual dose of insulin the morning of 1/3 to ½ of usual dose of insulin the morning of

surgerysurgery IV D5W with 20 meq KCl at 100 cc/hIV D5W with 20 meq KCl at 100 cc/h Monitor glucose q 1-2 hMonitor glucose q 1-2 h Use sliding scale q 4-6 h Use sliding scale q 4-6 h After procedure give usual evening dose of After procedure give usual evening dose of

insulin if eatinginsulin if eating

The Basics: DMThe Basics: DM

Type I or Type II on Insulin (longer Type I or Type II on Insulin (longer procedures)procedures)

Insulin infusionInsulin infusion Run with IV 2/3 + 1/3 or D5WRun with IV 2/3 + 1/3 or D5W Hourly glucoscansHourly glucoscans

Start insulin infusion Start insulin infusion

If BS If BS Insulin R units/hrInsulin R units/hr

0-40-4 No insulin; treat hypoglycemiaNo insulin; treat hypoglycemia

4.1-84.1-8 1 u/hr1 u/hr

8.1-108.1-10 2 u/hr2 u/hr

10.1-1210.1-12 4 u/hr4 u/hr

12.1-1412.1-14 6 u/hr6 u/hr

14.1-1614.1-16 8 u/hr8 u/hr

16.1-1816.1-18 10 u/hr10 u/hr

> 18> 18 10 u/hr and call MD10 u/hr and call MD

Back to the patientBack to the patient

You order ½ the dose of his usual morning You order ½ the dose of his usual morning dose of insulindose of insulin

You ask for frequent glucoscans and write You ask for frequent glucoscans and write an order for a sliding scale of insulinan order for a sliding scale of insulin

His Metformin is held the morning of the His Metformin is held the morning of the procedureprocedure

Case 2 Case 2

The patient is now POD # 2 for open The patient is now POD # 2 for open cholecystectomycholecystectomy

Called to assess for new onset of Called to assess for new onset of confusionconfusion

Case 2Case 2

Past Med Hx: DM II, CAD, HTN, COPDPast Med Hx: DM II, CAD, HTN, COPD Rx: ASA, ACE-I, beta-blocker, statin, Rx: ASA, ACE-I, beta-blocker, statin,

Metformin, insulin, inhaled bronchodilatorsMetformin, insulin, inhaled bronchodilators Demerol for post-op painDemerol for post-op pain LMWH for DVT prophylaxisLMWH for DVT prophylaxis

Case 2Case 2

According to nurse, the patient seemed According to nurse, the patient seemed lucid earlier that daylucid earlier that day

On arrival, the patient appears confused On arrival, the patient appears confused and is not oriented to either time or placeand is not oriented to either time or place

Unable to provide a history or answer Unable to provide a history or answer questions appropriatelyquestions appropriately

Case 2Case 2

On examinationOn examination Vitals are stable and patient is afebrileVitals are stable and patient is afebrile Patient is alert but inattentivePatient is alert but inattentive Mucus membranes are dry, JVP flatMucus membranes are dry, JVP flat No focal neurologic deficitsNo focal neurologic deficits Chest clearChest clear Normal heart sounds, no murmursNormal heart sounds, no murmurs Abdomen benign, wound looks fineAbdomen benign, wound looks fine

DeliriumDelirium

Disturbance of consciousness with reduced Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.ability to focus, sustain, or shift attention.

Change in cognition/new perceptual disturbance Change in cognition/new perceptual disturbance that is not better accounted for by dementia.that is not better accounted for by dementia.

Develops over a short period of time (usually Develops over a short period of time (usually hours to days) and tends to fluctuate during the hours to days) and tends to fluctuate during the course of the day.course of the day.

Presumed to be caused by a medical condition, Presumed to be caused by a medical condition, substance intoxication, or medication side effect.substance intoxication, or medication side effect.

DeliriumDelirium

CommonCommon 10-50% of elderly surgical patients10-50% of elderly surgical patients

Results in prolonged hospitalizationResults in prolonged hospitalization High mortality (14% at 1 month, 22% at 6 High mortality (14% at 1 month, 22% at 6

months)months)

ConfusionConfusion

Stuctural Non-structural

•CVA•Tumor•Blood•Seizure•Trauma•Abscess

•Infection•CNS, other

•Metabolic•Na, Ca, Liver, Renal

•Endocrine•Thyroid, Glucose,

•Drugs and Toxins•Also withdrawal

•Hypercapnia•Hypoxia

Risk Factors for Delirium Risk Factors for Delirium

PolypharmacyPolypharmacy Untreated painUntreated pain Opioids (esp Opioids (esp

Demerol)Demerol) InfectionInfection ImmobilityImmobility Bladder cathetersBladder catheters Frequent room Frequent room

changeschanges

ICU stayICU stay No windows in roomNo windows in room No eyeglasses or No eyeglasses or

hearing devicehearing device Dementia or organic Dementia or organic

brain diseasebrain disease Advanced ageAdvanced age MalnutritionMalnutrition

Working up DeliriumWorking up Delirium

History and physical examinationHistory and physical examination Review medications, history of EtOH or Review medications, history of EtOH or

benzosbenzos LabsLabs

CBC, Urinalysis, Lytes, calcium, glucose, CBC, Urinalysis, Lytes, calcium, glucose, LFTs, Cr, ABG, CXR,LFTs, Cr, ABG, CXR,

+/- Tox screen, +/- Drug levels+/- Tox screen, +/- Drug levels Other investigations as neededOther investigations as needed

CT head, EEG, LPCT head, EEG, LP

Prevention and Treatment of Prevention and Treatment of DeliriumDelirium

Treat underlying causeTreat underlying cause Maintain hydrationMaintain hydration Avoid restraints; mobilize if possibleAvoid restraints; mobilize if possible Treat painTreat pain Reduce noiseReduce noise Orienting stimuli (window, clock, calendar)Orienting stimuli (window, clock, calendar) Reassurance, bedside sitter, familiar facesReassurance, bedside sitter, familiar faces Neuroleptics if necessaryNeuroleptics if necessary Benzodiazepines, as adjunctBenzodiazepines, as adjunct

Back to the PatientBack to the Patient

Investigations reveal dehydration and a Investigations reveal dehydration and a UTI and he is started on antibiotics and IV UTI and he is started on antibiotics and IV fluidsfluids

Demerol replaced with Dilaudid plus Demerol replaced with Dilaudid plus regular Acetaminophen and NSAIDsregular Acetaminophen and NSAIDs

His family brings in his eyeglasses as well His family brings in his eyeglasses as well as his wristwatch and agree to stay with as his wristwatch and agree to stay with him as much as possible while he is him as much as possible while he is confusedconfused

Case 3Case 3

2 days later some routine labs reveal that 2 days later some routine labs reveal that your patient’s Cr has increased to 320 your patient’s Cr has increased to 320 (from baseline of 180)(from baseline of 180)

Case 3Case 3What do you want to know?What do you want to know?

MedicationsMedications ASA, ACE-I, beta-blocker, statin, Metformin, ASA, ACE-I, beta-blocker, statin, Metformin,

narcotics, acetaminophen, LMWHnarcotics, acetaminophen, LMWH NSAIDs q4h for post-op painNSAIDs q4h for post-op pain

Contrast dyeContrast dye CT head with contrast during delirium work-upCT head with contrast during delirium work-up

Urine output Urine output MinimalMinimal

Volume statusVolume status EuvolemicEuvolemic

Indications for urgent dialysisIndications for urgent dialysis

Pre-Renal Renal Post-Renal

HypovolemiaRenal perfusion

ATNGNAIN

Renovascular

Prostatic Bilateral ureteric

Approach to Renal FailureApproach to Renal Failure

Assess volume statusFENa

Review medsContrastUrine R&M (Casts,ProteinBlood)

Foley cathetherRenal U/S

Commonest causes of ARF in Commonest causes of ARF in hospitalized patientshospitalized patients

ATN 45%ATN 45% Contrast dye, shockContrast dye, shock

Pre-Renal 21%Pre-Renal 21% Diuretics, CHF, ACE-I, NSAIDsDiuretics, CHF, ACE-I, NSAIDs

Acute on Chronic 13%Acute on Chronic 13% Obstruction 10%Obstruction 10% GN or vasculitis 4%GN or vasculitis 4% AIN 2%AIN 2%

Antibiotics, NSAIDSAntibiotics, NSAIDS

Approach to ARFApproach to ARF

Assess if acute indications for dialysisAssess if acute indications for dialysis Review medications Review medications Urine R & MUrine R & M Serum and urine electrolytes (FENa) Serum and urine electrolytes (FENa) Foley catheter, Renal U/SFoley catheter, Renal U/S


Assess for acute indications for dialysisAssess for acute indications for dialysis Hyperkalemia (if high ask for EKG)Hyperkalemia (if high ask for EKG) AcidosisAcidosis Volume overloadVolume overload Uremic PericarditisUremic Pericarditis


Stop medications Stop medications ACE-I ACE-I NSAIDsNSAIDs Metformin (risk of lactic acidosis)Metformin (risk of lactic acidosis) LMWHLMWH Consider different antibioticConsider different antibiotic

Dose-adjust medications as neededDose-adjust medications as needed AntibioticsAntibiotics


Urine R & MUrine R & M Hematuria, Proteinuria Hematuria, Proteinuria CastsCasts

Granular – ATNGranular – ATN WBC – AINWBC – AIN RBC – GN, vasculitisRBC – GN, vasculitis


Serum and urine electrolytes (FENa) Serum and urine electrolytes (FENa)

Urine Na x Plasma CrUrine Na x Plasma Cr x 100 x 100

Plasma Na x Urine CrPlasma Na x Urine Cr

< 1% suggest volume depletion< 1% suggest volume depletion IV fluids if indicatedIV fluids if indicated


Rule out post-renal causesRule out post-renal causes Insert Foley CatheterInsert Foley Catheter Renal U/SRenal U/S


He has no acute indication for dialysisHe has no acute indication for dialysis Urine R & M reveals several granular Urine R & M reveals several granular

castscasts Renal U/S reveals no evidence obstructionRenal U/S reveals no evidence obstruction FENa is > 1%FENa is > 1% Consistent with ATN, probably related to Consistent with ATN, probably related to

contrast dyecontrast dye

Contrast-induced nephropathyContrast-induced nephropathy

Incidence increases as GFR decreasesIncidence increases as GFR decreases Renal failure starts almost immediatelyRenal failure starts almost immediately Recovery begins within 3-5 daysRecovery begins within 3-5 days

Contrast-induced nephropathyContrast-induced nephropathyRisk FactorsRisk Factors

Renal insufficiency (GFR < 60ml/min)Renal insufficiency (GFR < 60ml/min) Diabetic nephropathyDiabetic nephropathy Advanced CHFAdvanced CHF High dose contrastHigh dose contrast Multiple MyelomaMultiple Myeloma

Contrast-induced nephropathyContrast-induced nephropathyPreventionPrevention

Mucomyst 600mg PO BID for 2 daysMucomyst 600mg PO BID for 2 days HydrationHydration 3 amps of bicarb in 1 litre of D5W at 3 amps of bicarb in 1 litre of D5W at

3.5ml/kg/hr for 1 hour pre and 1.2ml/kg/hr 3.5ml/kg/hr for 1 hour pre and 1.2ml/kg/hr for 6 hours post contrastfor 6 hours post contrast

Case 4Case 4

A few days later, you are called to see the A few days later, you are called to see the patient for sudden onset of dyspneapatient for sudden onset of dyspnea

Case 4Case 4

On arrival patient appears to be in On arrival patient appears to be in moderate respiratory distressmoderate respiratory distress

Reports SOB. Denies chest pain, cough, Reports SOB. Denies chest pain, cough, hemoptysis, or calf painhemoptysis, or calf pain

Case 4Case 4

Sats 92% FiO2 .50, RR 30, HR 120, BP 170/90, Sats 92% FiO2 .50, RR 30, HR 120, BP 170/90, afebrileafebrile

Alert, talking in short sentencesAlert, talking in short sentences Sitting up in bed, using accessory musclesSitting up in bed, using accessory muscles JVP elevatedJVP elevated Crackles heard bilaterallyCrackles heard bilaterally Normal S1/S2, S3 present, no murmur Normal S1/S2, S3 present, no murmur No leg edema, no calf asymmetryNo leg edema, no calf asymmetry

Case 4Case 4

Past Med Hx: DM II, CAD, HTN, COPDPast Med Hx: DM II, CAD, HTN, COPD Rx: ASA, beta-blocker, statin, insulin, Rx: ASA, beta-blocker, statin, insulin,

inhaled broncholdilatorsinhaled broncholdilators Dilaudid, Acetaminophen for post-op painDilaudid, Acetaminophen for post-op pain DVT prophylaxisDVT prophylaxis

Differential DiagnosisDifferential Diagnosis

CHFCHF PEPE Pneumonia or aspirationPneumonia or aspiration COPD/AsthmaCOPD/Asthma Mucus PluggingMucus Plugging Cardiac ischemia, arrhythmiaCardiac ischemia, arrhythmia Other (pneumo or hemothorax, tamponaade, Other (pneumo or hemothorax, tamponaade,

effusion, anemia, acidosis)effusion, anemia, acidosis)

Initial ManagementInitial Management

ABCsABCs Order investigationsOrder investigations

EKGEKG CXRCXR ABGABG LabsLabs

CBC, Lytes, Urea, Cr, Cardiac EnzymesCBC, Lytes, Urea, Cr, Cardiac Enzymes

Kerly B LineCardiomegaly

Vascular redistribution

Peribronchial cuffing

Pulmonary EdemaPulmonary Edema

Treating Acute Pulmonary EdemaTreating Acute Pulmonary Edema

LMNOPLMNOP OxygenOxygen LasixLasix NitratesNitrates MorphineMorphine Positioning, Positive Pressure (BIPAP)Positioning, Positive Pressure (BIPAP) Intubation (hopefully avoidable)Intubation (hopefully avoidable)

Determining Cause CHFDetermining Cause CHF

Iatrogenic (stopping patient’s diuretics, Iatrogenic (stopping patient’s diuretics, aggressive IV fluids)aggressive IV fluids)

Echo (systolic/diastolic dysfunction, Echo (systolic/diastolic dysfunction, valvular dysfunction)valvular dysfunction)

Ischemia/InfarctionIschemia/Infarction ArrhythmiaArrhythmia

Back to the PatientBack to the Patient

EKG revealed no evidence of ischemiaEKG revealed no evidence of ischemia No rise in cardiac enzymesNo rise in cardiac enzymes Echo revealed EF 35%, aortic sclerosisEcho revealed EF 35%, aortic sclerosis Patient had received several litres of NS Patient had received several litres of NS

and his diuretics had been stopped on and his diuretics had been stopped on admissionadmission

Improved with diuresisImproved with diuresis

Case 5Case 5

The patient has been recovering from his The patient has been recovering from his surgery and is no longer in CHF. He is surgery and is no longer in CHF. He is almost ready to go home but routine almost ready to go home but routine bloodwork reveals hyponatremia (Na 122).bloodwork reveals hyponatremia (Na 122).

HyponatremiaHyponatremia

Common Common Incidence 4.4% post-opIncidence 4.4% post-op

Why do patients get hyponatremic post-Why do patients get hyponatremic post-op?op? Fluid shiftsFluid shifts

IV fluid, third spacing, irrigationIV fluid, third spacing, irrigation Stress of surgery (increased ADH)Stress of surgery (increased ADH) HyperglycemiaHyperglycemia

Commonest causes Post-opCommonest causes Post-op

Euvolemic (SIADH) – 42%Euvolemic (SIADH) – 42% Hypervolemic – 21%Hypervolemic – 21% Hyperglycemia – 21%Hyperglycemia – 21% Hypovolemia – 8%Hypovolemia – 8% Renal failure – 8%Renal failure – 8%

Hypervolemic

Isotonic

Euvolemic Hypovolemic

Measure serum osmolality

HypertonicHypotonic

HyperproteinemiaHyperlipidemia

HyperglycemiaMannitol

CHFCirrhosisNephrotic

SIADHPsychogenicEndocrine

Drugs

Renal lossesGI losses

Third spacing

Approach to HyponatremiaApproach to Hyponatremia

Serum lytes and osmolalitySerum lytes and osmolality GlucoseGlucose Volume statusVolume status Urine lytes and osmolalityUrine lytes and osmolality


Serum lytes, glucose, and osmolalitySerum lytes, glucose, and osmolality Usually hypotonicUsually hypotonic If isotonic consider pseudohyponatremiaIf isotonic consider pseudohyponatremia If hypertonic consider hyperglycemia, If hypertonic consider hyperglycemia,

mannitolmannitol


Volume statusVolume status If hypotonic, assess volume statusIf hypotonic, assess volume status


Urine lytes and osmolalityUrine lytes and osmolality Normal response to hyponatremia is to Normal response to hyponatremia is to

suppress ADH secretion: low urine osmolalitysuppress ADH secretion: low urine osmolality Urine Na will be low if hypovolemiaUrine Na will be low if hypovolemia Interpret with caution if on diureticsInterpret with caution if on diuretics

In SIADHIn SIADH Urine osmolality > 100, usually > 300Urine osmolality > 100, usually > 300 Urine Na > 20, usually > 40Urine Na > 20, usually > 40

Treatment of HyponatremiaTreatment of Hyponatremia

Avoid rapid correction due to risk of central Avoid rapid correction due to risk of central pontine myelinolysispontine myelinolysis

Correct by 0.5-1 mEq/hourCorrect by 0.5-1 mEq/hour


HyervolemicHyervolemic Fluid and Na restrictFluid and Na restrict DiureticsDiuretics

EuvolemicEuvolemic Fluid restrictionFluid restriction 1.5 litres/d1.5 litres/d


HypovolemicHypovolemic IV NSIV NS Usually about 75cc/hrUsually about 75cc/hr

Change in serum Na = Change in serum Na = infusate Na – serum Nainfusate Na – serum Na

total body water +1total body water +1

Estimates the effect of 1 litre of any infusate on serum NaEstimates the effect of 1 litre of any infusate on serum Na

NS = 154 mmol/litreNS = 154 mmol/litre


Hypertonic saline in extreme casesHypertonic saline in extreme cases i.e. Seizure i.e. Seizure Assistance from ICU or Internal MedicineAssistance from ICU or Internal Medicine


Examination reveals dry MM, flat JVPExamination reveals dry MM, flat JVP Serum Na is 122, Serum osmolality is lowSerum Na is 122, Serum osmolality is low Urine osmolality is 150, Urine Na is <10Urine osmolality is 150, Urine Na is <10 Consistent with hypovolemic Consistent with hypovolemic

hyponatremia, likely secondary to hyponatremia, likely secondary to aggressive diuresisaggressive diuresis

The patient is treated with IV NS at The patient is treated with IV NS at 75cc/hr with 40 mEq KCl/litre75cc/hr with 40 mEq KCl/litre

Case 6Case 6

The patient’s nurse calls you with a The patient’s nurse calls you with a critical critical potassium of 6.8potassium of 6.8

What would you do for this patient?What would you do for this patient?

Stat ECGStat ECG Stop any potassium-containing Stop any potassium-containing

medications or IV fluidsmedications or IV fluids Stop medications that can contribute to Stop medications that can contribute to

hyperkalemia (ACE-I, Spironolactone)hyperkalemia (ACE-I, Spironolactone) Stabilize myocardium and treat Stabilize myocardium and treat

hyperkalemiahyperkalemia

Peaked T waves

Short QT

Prolonged PR

Also: widened QRS, sine wave, eventual v. fib

Treatment of HyperkalemiaTreatment of Hyperkalemia

Stabilizing the myocardiumStabilizing the myocardium Antagonism of membrane actions of K+Antagonism of membrane actions of K+ 1 amp Calcium Gluconate1 amp Calcium Gluconate


Shifting K+ into cellsShifting K+ into cells Insulin + GlucoseInsulin + Glucose

10 units R IV + ½ amp D50W10 units R IV + ½ amp D50W

Sodium bicarbonateSodium bicarbonate Beta-2 adrenergic agonistsBeta-2 adrenergic agonists

VentolinVentolin


Removal of K+ from the bodyRemoval of K+ from the body Cation exchange resinCation exchange resin

Kayexelate 30 g Kayexelate 30 g

Loop or thiazide diureticLoop or thiazide diuretic Dialysis if severeDialysis if severe


The patient is found to have an IV solution The patient is found to have an IV solution containing potassium which is stopped. containing potassium which is stopped. You stabilize him with calcium gluconate, You stabilize him with calcium gluconate, insulin and glucose and he receives insulin and glucose and he receives Kayexelate. The ECG changes resolve Kayexelate. The ECG changes resolve and repeat potassium is normal.and repeat potassium is normal.

Documents

The Medical Tune Up Dr. Debra Pugh MD, FRCPC Internal Medicine